| NPI | 1255353439 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363L00000X Nurse Practitioner (Licence: NY F330799-1) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: NY 362967-1) |
| Enumeration Date | 2006-07-24 |
| Last Update Date | 2009-02-10 |